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Reviewing Equitable Access to Healthcare Outcomes out of Hours and at the Weekend (REACH) Project

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Reviewing Equitable Access to Healthcare Outcomes out of Hours and at the Weekend (REACH) Project Reviewing Equitable Access to healthCare outcomes out of Hours and at the weekend (REACH) Project A review of health outcomes for patients admitted out of hours and at the weekend: is there an effect and what are the characteristics and contributing factors? Published by the State of Queensland (Queensland Health), May 2017 ISBN: 978-0-646-97198-8 This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au © State of Queensland (Queensland Health) 2017 You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Metro North Hospital and Health Service). For more information contact: Office of the Chief Executive, Level 14, Block 7, Royal Brisbane and Women’s Hospital, Herston Qld 4029 Phone: (07) 3647 9501 Email: [email protected] An appropriate reference for this publication is: Romeo, M., O’Gorman, R., and Bell, A. (2017). Reviewing Equitable Access to healthCare outcomes out of Hours and at the weekend (REACH) Project: A review of health outcomes for patients admitted out of hours and at the weekend - Is there an effect and what are the charateristics and contributing factors? Brisbane, Qld: State of Queensland (Metro North Hosptial and Health Services) doi: 10.13140/RG.2.2.33233.94568 An electronic version of this document is available at www.health.qld.gov.au/metronorth/publications Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information. Forward Does a patient admitted out of hours and at the weekend receive the same level of care as someone admitted during the week? It’s a question healthcare providers have long asked, but there has been no definitive answer. The Reviewing Equitable Access to healthCare outcomes out of Hours and at the weekends (REACH) Project aims to address the challenge of seven-day healthcare delivery from a Queensland perspective through analysis of existing research, safety and quality data, and anecdotal evidence from clinicians. This systematic review of literature provides a strong foundation for a Queensland wide data-linkage project that further examines the issue with the CSIRO. By understanding the variation in healthcare outcomes, we can examine strategic opportunities to provide the very best care available at any time. The REACH Project has been an important collaboration between Metro North Hospital and Health Service, Queensland Clinical Senate and Clinical Excellence Division, Queensland Health. It furthers our understanding of the nature of healthcare outcomes for patients admitted to public hospitals out of hours and at weekends. Through this study, we have found that a number of factors – protective care mechanisms, staffing profiles and system efficiencies – may be key to understanding why one patient has better outcomes than another regardless of their admission day. I commend the Queensland Clinical Senate and Metro North Hospital and Health Service for undertaking this important piece of work to ensure equitable healthcare access for all Queenslanders. Ken Whelan Dr John Wakefield PSM Metro North HHS Deputy Director, Executive Officer Clinical Excellence Division Reviewing Equitable Access to healthCare outcomes out of Hours and at the weekend (REACH) Project I Executive Summary This review was commissioned by the Queensland Clinical Senate in 2015, in partnership with the Clinical Excellence Division, Queensland Health and Metro North Hospital and Health Service, to inform research into health outcomes for patients admitted to Queensland hospitals out of hours and to influence the future development and implementation of best practice models of care. The objectives which guided the review were: • To identify and analyse the factors that influence inequality of health outcomes to patients admitted/presenting to hospital out of hours and at the weekend. • To identify the range and scope of services or other interventions specifically targeting inequality of health outcomes of patients admitted/presenting to hospital out of hours and at the weekend. • To identify care processes that have demonstrably reduced the inequality of health outcomes for patients admitted/ presenting to hospital out of hours and at the weekend. • To identify the potential application of the review findings in the Queensland setting and areas requiring further research. Overall, there is mixed evidence of inequitable outcomes for patients admitted out of hours, based predominantly on retrospective analysis of large administrative data sets. Clinical dataset analyses, which were often adjusted for severity of illness, are less supportive that differential outcomes exist. Where evidence does exist, it is limited to a small mortality differences, is condition specific so not generalisable across conditions and fails to address other morbidity or patient reported qualitative outcomes. Since a landmark study in 2001, 4 over 100 papers have explored the difference in outcome across a range of patient populations and health systems. Published literature in the area identifies a range of human resource, system and process considerations that may improve outcomes for patients admitted at these times. Many contributing factors are identified as being associated with or mitigating against differential mortality for patients admitted out of hours. These were generally hypothesised through the expert analysis by researchers when discussing their findings, rather than definitively tested to determine causality or multifactorial causal linkages. No published pre-and-post intervention studies could be identified, by this review, which specifically examined the impact on mortality that a given intervention, for example timeliness to investigation, treatment, models of care or staffing, may have had if a differential outcome had previously been identified. There are a number of limitations of the largely descriptive and retrospective studies included in this review making definitive recommendations from the literature difficult to make. In part, the questions that guided the review remain unanswered highlighting a number of gaps in our current knowledge. No studies identified any mechanisms that specifically targeted addressing unequal outcomes as a result of out of hours admission. Any methodological limitations, and the opportunity to explore patient outcomes beyond mortality differences, were noted as part of the review and have provided guidance to the development of a Queensland based data linkage outcome study which is under way. Whilst mortality remains an important quantitative patient outcome differential, any demonstrable differences will be broadened and viewed in the context of patient experience, staffing profiles and non-mortality patient outcome measures. The authors of this report have been wholly responsible for all data collection, analysis, interpretation and manuscript preparation in consultation with the REACH Project Steering Committee and Research Advisory Group. The findings of the review highlight the gaps in the literature regarding where improvement efforts should be targeted to reduce outcome variation, to then stimulate health services research into the impact of newly implemented interventions that will ultimately better inform strategic planning around the delivery of out of hours care. Reviewing Equitable Access to healthCare outcomes out of Hours and at the weekend (REACH) Project III Contents Chapter 1: Background .......................................................................................................................... 1 Differences in out of hours admissions compared to working hours ............................................. 1 Chapter 2: Criteria for considering studies for this review ............................................................... 2 Types of studies ............................................................................................................................ 2 Search strategies .......................................................................................................................... 2 Inclusion and exclusion criteria ..................................................................................................... 3 Data extraction .............................................................................................................................. 3 Quality review ................................................................................................................................ 5 Chapter 3: The size and consequence of differential outcomes for patients admitted to hospitals out of hours and at the weekend ......................................................................................... 6 Mortality rates ................................................................................................................................ 6 Treatment Delay ...........................................................................................................................
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